Abstract

Background: Mobile Training and Support (MOTS) service is the vehicle for delivery of refresher training on healthcare related topics. This service will provide mobile training to Community Health Workers (CHWs) via their mobile phones with feature phones as the basic requirement. The MOTS service will provide training modules via Interactive Voice Response (IVR) or voice messages that include units and quizzes and allow monitoring by management. The purpose of the study was to assess the functionality of CHWs and their readiness to receive the MOTS service package.
Method and Material: The study was a cross-sectional assessment utilizing both quantitative and qualitative data collection methods in Bo district, southern Sierra Leone found in West Africa. The tools had mixed method questions to capture both quantitative and qualitative data. Results: The CHWs’ willingness to participate in the MOTS service was 99.2% with 79.2% mobile phone functionality. This therefore meant that 79.2% of all CHWs surveyed met the inclusion criteria for the MOTS program. With 90.6% of the Peripheral Health Unit (PHU) in-charges proving to be supervising CHWs, only 40.63% of the PHU in-charges could actually provide supervision to CHWs for the MOTS program due to the need to own a smartphone.
Conclusions: Utilization of the modular IVRs through the MOTS service to facilitate the refresher training to CHWs is possible. This is because from the assessment 79.2% CHWs met the inclusion criteria for MOTS. At the CHW level, the willingness to participate was rated at 99%. This coupled with a 90.6% of PHU-Incharges readiness will contribute to the success of the program.

Keywords

Community health worker; Mobile training
and support service; Community health worker functionality;
Community system readiness; Community health worker
training

Introduction

The CHW policy guidance in Sierra Leone

When Sierra Leone faced the Ebola virus disease outbreak,
the country fought hard and made tremendous progress within
a short space of time to recover the healthcare system and
restore essential healthcare services. CHWs were acknowledged
to be part of this not as a business but as usual approach [1].
CHWs, many of whom had been working within their
communities for years, stepped up to meet the enormous
challenge and acted as contact tracers and members of burial
teams, and helped to spread messages of caution and hope to
their communities [2].

The President’s Recovery Priorities [3] set ambitious targets
for the country, including saving the lives of 600 women and
5,000 children by 2018, as outlined in Key Result Area 1,
strengthening the National CHW Program. As Sierra Leone
continues to face the world’s highest maternal and child mortality rates, reaching every child and woman with essential,
life-saving interventions is important, and requires active
participation of the community. CHWs bridge the gap between
the health facilities by bringing the clinic to communities and
communities to the clinic [4]. Further the Trinity college of
Dublin study points out that CHWs and mobile technology can
go a long way in improving health in the community. From the
last step there are still difficult challenges to tackle in achieving
sustainable child and maternal health [5]. Using mHealth and
CHW to improve health outcomes is an interesting case of how
collaboration between organisations can achieve SDG [3].

The National CHW Policy and Strategy, employs a
government-led, health- and community-systems strengthening
approach that aims to make the CHW Program stronger and
better integrated with the overall health system. The changes
relate to governance, programmatic details, and support to the
CHWs themselves. There is a structure within the MoHS that is
fully dedicated to overseeing the program, including direct
fundraising, with funds flowing directly through the MoHS. This
is aligned with the numerous partnership agreements that Sierra
Leone has signed, including the Paris Declaration and the Abuja
Accord [1].

Capacity building of CHWs in the rapid infectious
disease outbreak era

Understanding how large outbreaks and their management
might influence the reporting and delivery of community-based
healthcare is critical to the design of resilient health systems in
the face of future outbreaks, particularly in settings with preexisting
gaps in facility-based care [6]. It was concluded generally
that the CHW Program demonstrated vulnerability, but also
resilience, during and in the early period after the Ebola
outbreak. Investment in CHWs is required to strengthen the
healthcare system, as they can cover pre-existing gaps in facilitybased
healthcare and those created by outbreaks [7-9]. Having
innovative approaches to refresh and retrain CHWs without
necessarily having them in workshop contact classes is
important to facilitate the momentum.

The Ebola crisis in West Africa has led to the consideration on
how CHW work relates to the situation, both in the present and
going forward. Implementing partners focused on how CHWs
are keenly aware of the Ebola crisis, as front-line workers and
can be decisive in the success or failure of crisis responses. The
global health partners are aware of the critical role of CHWs in
epidemic situations like Ebola, highlighting the need for
community knowledge and sensitization, contact tracing and
surveillance. This necessitates training CHWs and other health
workers on Ebola control activities, sensitization techniques, and
safety measures. Accurate information dissemination by CHWs
can help control Ebola infection but also help lower the risk of
indirect deaths caused by misdiagnosis of conditions like
malaria, which is presented in similar ways to Ebola [10,11].

CHWs worldwide played an important role in working towards
the health related Millennium Development Goals (MDGs). Their
contributions extended from work on reducing child mortality
and improving maternal health, to combating HIV/AIDS, malaria
and other diseases. CHWs seem to be emerging from the
shadows. The current Sustainable Development Goals (SDGs)
momentum around CHWs has a number of reasons why this is
happening. Among others, SDG targets explicitly ask
governments to increase health financing and recruitment,
development, training and retention of the health workforce
[12]. The deployment of CHWs is increasingly considered as a
key strategy to respond to the scarcity of health personnel,
particularly in low-income and middle-income countries. There
is strong evidence that if appropriately and adequately trained
and supported CHWs can be effective in providing preventive, promotive and limited curative primary healthcare services and
improving health outcomes [13].

The mobile training and support (MOTS) service
innovation

The Ebola vaccine Deployment, Acceptance and Compliance
(EBODAC) project was established to develop strategies and
tools to promote the acceptance and uptake of new Ebola
vaccines [14]. The overall objective of EBODAC is to develop a
communication and engagement strategy including the
development of appropriate technology and tools [14,15] like
the MOTS in order to maximize Ebola vaccination impact in the
targeted population. It implies developing, testing and
implementing all necessary activities, pilots and tools to ensure
acceptance and compliance with the Ebola vaccination program
in Africa, both in support of clinical trials and in the broader
vaccination program beyond the clinical trial in case of a
licensed vaccine.

The Community Health Worker (CHW) is the backbone of the
healthcare system at the household level [16-18] in Sierra Leone
and the focus and objective of the MOTS component is to
strengthen this network to ensure preparedness for Ebola
vaccine campaigns and outbreak response. The project will set
up the MOTS service that is the vehicle for delivery of the
refresher training, initially focusing on the topics of Vaccines and
Outbreak Response. This service will provide mobile training to
CHWs via their mobile phones with feature phones as the basic
requirement [19]. The MOTS service will provide training
modules that include units, quizzes, allow monitoring by
management and utilisation of the Visual aid during training.

MOTS identifies opportunities to train CHWs more costeffectively
through technology-enabled multimedia content that
leverages audio through an Interactive Voice Response (IVR)
system. In collaboration with diverse stakeholders such as
Ministry of Health and Sanitation (MoHS), District Health
Management Team (DHMT) and lower level chiefdom
authorities, MOTS innovative design and energetic adoption
would make a standout in its new approaches to rural CHWs
epidemic response [20].

Main Objective

To assess the functionality of CHWs and readiness to receive
the MOTS service package.

Sub-objectives of the study

• To assess the readiness of the CHWs to participate in the
MOTS

• To assess the readiness of the CHW system structures to
support MOTS

• To perform the functionality of CHWs in relation to the
agreed inclusion criteria

Justification of the study

The implementation of the MOTS was agreed upon with the
MoHS structures that are responsible for CHWs, Health
Promotion and Education, Expanded Program on Immunisation
and the e-Health working group. It was agreed that MOTS would
be a refresher service that will be used to provide innovative
capacity building of CHWs that have already undergone the
MoHS recommended training modules. A given set of inclusion
criteria was agreed upon that was supposed to be followed in
order to enroll the CHWs into the MOTS service. The study
therefore set out to provide a platform for CHWs and program
components that support the CHWs work to prove their ability
to participate in the program.

Methodology

The study design

The evaluation was conducted as a cross-sectional assessment
that utilized both quantitative and qualitative data collection
methods. The tools had mixed method questions to capture
both quantitative and qualitative data.

Study area

The study was conducted in Bo district in the Southern
Province of Sierra Leone found in West Africa. It is the second
most populous district in Sierra Leone after the Western Area
Urban District. Its capital and largest city is the city of Bo, which
is the second largest city in Sierra Leone. The study covered 5
major chiefdoms of Bagbo (5,403 population), Jaiama Bongor
(31,298 population), Bumpe-Gao (44,279 population), Lugbu
(25,453 population) and Tikonko (53,206 population) with a
51.2% female and 48.8% male population disaggregation [21].

The study followed follows the MoHS implementation structure
(Figure 1).

Figure 1: Health facility structure in Sierra Leone

The target population groups

The target population was the users of the MOTS service
based on the MoHS recommended implementation and
supervision structure for the CHWs in the implementation sites
(Table 1).

No.

Target population

Required numbers

Justification of population inclusion

1

CHWs

300

The CHWs are expected to be the users of the system and receive mobile training through self-service. They are the primary participants in the study. The Pilot requires 125 CHWs in total so for the functionality assessment a larger number was required to be able to select the 125 active CHWs.

2

PHU in-charges

45

The in-charges will have access to reports on how their CHWs are performing and do follow up on those that have not yet completed a given module. A census of all PHUs needed to be included since CHW selection was expected to come from any PHU in the study area.

3

DHMT

4

Level 1 Administrators will mainly interact with the system via a web interface or a smartphone app for MOTS and have access to reports. In the systems strengthening approach the members of the DHMT supervise the in-charges and oversee all capacity building in the district. The District has 4 authorities that deal directly with the CHWs.

4

MoHS

4

Level 2 Administrators will be responsible for defining module structure and uploading course content into the MOTS system. In the systems strengthening approach, it’s the MoHS that is responsible for planning and implementing capacity building. Even in MoHS, the MoHS takes this role. The Bo district is in the southern region with 4 focal points at MoHS responsible for this role from 4 key sectors of: Community health, Immunisation, E-Health and Health promotion.

5

Household members

300

The overall anticipation is that the CHWs shall use the knowledge acquired through MOTS to boost up their counselling activities at the community level and therefore the inclusion of this sample. Each CHW selected shall mean inclusion at least one household from his catchment area.

Table 1: Targeted populations

Sample size determination and justification

The study followed a number of sampling techniques
depending on the requirement of the given sample. The
chiefdoms were purposively selected because they fall under the
operational area of World Vision Sierra Leone in Bo district. This
further influenced the PHUs to be included in the study. Since
the 5 chiefdoms have 45 PHUs, the study includes all the PHU incharges
as a census.

Focusing on the 300 CHWs, the project utilized the random
sampling method using the table of random numbers. All the
chiefdoms provided an equal sample to the study. Each CHW
chosen meant that households from his catchment would be
selected. The utilization of only 300 CHWs was linked to
availability of resources for the project. The 300 household
samples were aligned to the number of CHWs sampled. The
assumption was that each CHW interviewed provided a sample
of one locality from which a household would be interviewed
and therefore an equal sample. The MoHS and DHMT included
in the study are those that directly supervise CHW work in Bo
region.

Data collection tools

The CHW Functionality Assessment Questionnaire Tool was
used to assess CHW readiness to use MOTS. The information
collected using this tool is what was used to determinate which
CHWs met the inclusion criteria for MOTS. To assess the status
and readiness of the immediate CHW supervisors at the PHUs,
the CHW in-charges Functionality Assessment Questionnaire
Tool was developed. This was used to gather perspectives from
the PHU in-charges. To assess the status of the readiness for the
MoHS structures to support the implementation of MOTS, the
DHMT/CHW-Hub Functionality Assessment Questionnaire Tool
was used. This tool focused on the MoHS CHW Hub team
members and the DHMT staff who are directly responsible for
the CHW interventions. To assess the contribution of the CHWs
to the households in the catchment area, the Households
Service Delivery Tool was used. This was to assess the
perceptions of the community as far as the content of the two
modules are concerned.

Enrolment criteria into the MOTS service

For each category of study participants, there was a given
inclusion criterion to be met to be able to go beyond just being a
sampled participant. Since the assessment was meant to determine the functionality and therefore inclusion into the
actual MOTS roll out process. Table 2 presents the agreed
inclusion criteria per sample.

No.

Target population

Inclusion criteria

1

CHW

Willing to fully participate in the pilot. Must be reporting to the PHU. Must have a functional mobile phone. Should be based in the geographical location of the PHU assigned.

2

PHU in-charges

Must have a smartphone. Should be supervising the CHWs.

3

DHMT

Must have a functional laptop, internet connectivity.

4

MoHS

Must have a functional laptop, have supervisory roles to the geographical location.

5

Community members

Must be residents in the geographical location of the eligible PHU. Should have been visited by the CHW who has been included in the study. Willing to participate in the study.

Table 2: Program inclusion criteria

Data analysis

Data was entered into Excel on a daily basis by the data
entrants, and a two-stage cleaning process was established.
Firstly, the Lead Data Manager combined and reviewed all
entered data and provided feedback to the data entrant team on
any misunderstood pieces of data. If the coded fields were not
clearly marked, the field team, during the review process was
consulted on the interpretation. The second stage of data
cleaning was done by the two project statisticians. All
quantitative data was analyzed using Excel, into absolute
numbers then percentages basing on the totals. While
qualitative data was analyzed through a review process that
facilitated the generation of commonalities in the responses,
then clustered into major themes and ideas and these were
ranked and turned into quantitative data.

Data privacy

The collection and processing of CHW data was limited to the
data necessary to fulfil the MOTS objectives and as approved by the MoHS of Sierra Leone. This is because the information that
was collected from the CHWs included very sensitive and
privileged data. This data was collected and processed with
adequate precautions to ensure confidentiality and compliance
with applicable data privacy protection laws and regulations as
set in the MOTS protocol of implementation. Appropriate
technical and organizational measures to protect the personal
data against unauthorized disclosures or access, accidental or
unlawful destruction, or accidental loss or alteration was
observed. Key personnel whose responsibilities require access to
personal data agreed to keep the identity of CHWs confidential.

Ethical consideration

The study sought and obtained ethical approval from the
Office of the Sierra Leone Ethics and Scientific Review
Committee of Ministry of Health and Sanitation Directorate of
Policy, Planning and Information (DPPI) Youyi Building, Fifth
Floor, East Wing before it was conducted. In addition, the study
was approved under version number 12/03/2017. Informed consent was sought from the households interviewed by signing
on the administered consent form (ICF).

Study limitations

The data collection exercise was conducted during the period
just preceding national elections, with some CHWs and
respondents being actively involved in the political activities and
not available at the time the research teams needed their
support.

Some of the randomly selected CHWs and villages were
unreachable by normal means of transportation. Most of the
times, it was not possible to meet the targeted number of
respondents for the day. The team had to extend working hours
in order to achieve the targeted population for the study.

The data collection process coincided with the PHU in-charges
monthly meeting at the district headquarters. This affected the
planned PHU in-charges census as some of them were not
reachable at their PHUs.

Results

For all the specific results summarized in this section, please
see the corresponding tables and figures section designated in
this paper

Social demographic characteristics of participants

The study attracted 264 CHWs representing 88% of the target
for inclusion into the study. The 12% CHWs that were not
included into the study even when sampled were not reached
due to the geographical challenges of the terrain, and nonavailability
due to participation in post political events during
the survey period. 74% of the CHWs interviewed were male
while only 26% were female. 303 household members were
interviewed, representing 101% of the sampled population. The
household population interviewed was a deviation from that of
the CHWs by sex representing 70% female and 30% male. The
interviews happened during the day and therefore it was the
females that were found at the household during that time. The
study also managed to interview 32 PHU in-charges out of the
45 planned censuses representing a 71% fulfilment. The 29% of
PHU in-charges not interviewed were not available due to the
post-election activities in the Bo district at the time of the
survey.

The study also focused on the allocation of CHWs and PHU incharges
by level of PHU. For the CHWs interviewed, 41% were
drawn from Community Health Centers (CHCs), 34% from
Community Health Posts (CHPs) and 25% from Maternity
Community Health Posts (MCHPs). This was because in
accordance to the MoHS Guidelines, a CHC covers a large
geographical area and therefore during sampling provided a
large sample size for CHWs to draw from. The geographical
frame then decelerated to the CHP and finally to the MCHP [22].
However, when it came to the inclusion of PHU in-charges into
the study, the MCHP provided 50% of all the in-charges into the
study, CHC provided 34% of the study subjects and CHP provided
only 16%. The order was supposed to be MCHP, CHP and then lastly CHC and this would have been because of the MoHS
structure provides for more MCHP, followed by CHP and then
CHC since this provision follows the referral pathway [23] as
shown in Figure 1, and the care provided. This was not the case
since most CHPs visited did not have the PHU in-charges present
due to the post-election activities during the study period.

Focusing was on the distribution of study participants by
chiefdom. When it comes to the CHWs who participated, 25%
were selected from Bumpe as the highest provider and Jiama
Bongor provided the least standing at 13%. At the sampling
time, each chiefdom provided an equal number, however as
highlighted earlier, some participants were not readily available
at the study time. The highest provider of participants for the
household survey was Jiama Bongor with a 29%, followed by
Bumpe with a 21%. The chiefdom that provided the least
participants was Bagbo with a 13% of the 303 participants
interviewed. The project set out to perform a census for the 45
PHUs however not all participated. From the 5 chiefdoms,
Bumpe PHU in-charges were readily available with a 34%
provision. The least chiefdom availing PHU in-charges was Bagbo
with a 6% provision.

One other demographic feature that was assessed for CHWs
alone was age. The age category 46-55 years provided the
highest percentage of CHWs, 34%. There were only 3% of the
CHWs in the age category below 25 years with 8% of the CHWs
coming from the age category of above 66 years. The study
revealed a very interesting dynamics that is; 61% of the CHWs
being above 46 years. This is the age category that is considered
not youthful. This has an advantage of having mature CHWs that
have experience and may be used for influencing and
supervising the youthful age [24]. However, for the utilization of
mobile technology, it is mostly believed that the age of
preference for the CHW to navigate the system would be below
45 years [25]. The younger the CHWs, the more technology
compliant they would be because they are considered more
technologically active than the older CHWs (Table 3a-3d) [26].

No

Sex

CHWs

House Hold

No

%

No

%

1

Male

141

74.00

89

29.00

2

Female

70

26.00

214

7.0

Grand Total

264

303

Table 3a: Social demographic characteristics of participants by
sex.

No

Chiefdom

CHWs

House Hold

PHU-i

No

%

No

%

No

%

1

Bagbo

61

23.00%

40

13.00%

2.00

6.00%

2

Bumpe

65

25.00%

63

21.00%

11

34.00%

3

JiamaÃÂ Bongor

35

13.00%

87

29.00%

4.00

13.00%

4

Lugbu

42

16.00%

54

18.00%

7

22.00%

5

Tikonko

61

23.00%

59

19.00%

8

25.00%

Grand Total

264

303

32

PHU-i: PHU-incharge

Table 3b: Social demographic characteristics of participants by
location.

No

PHU Level

PHU-i

CHWs

No

%

No

%

1

CHC

11

31.00%

107

41.00%

2

CHP

5

16.00%

91

34.00%

3

MCHP

16

50.00%

66

25.00%

Grand Total

32

264

PHU-i: PHU-incharge

Table 3c: Social demographic characteristics of participants by
Level of PHU attached to.

No

Age

No

%

1

<25yrs

7

3.00%

2

26-35yrs

46

18.00%

3

36-45yrs

47

19.00%

4

46-55yr

87

34.00%

5

56-66yrs

47

19.00%

6

>66yrs

19

8.00%

Table 3d: Social demographic characteristics of participants by
Age categorisation of CHWs.

CHW readiness to participate in the MOTS

One of the key readiness considerations was CHWs willingness
to actually be trained [27] through a mobile platform. The
CHWs’ willingness to be trained using a mobile phone was
assessed by their level of acceptance to receive IVRs through the
phone as refresher. Almost all CHWs (99%) showed acceptance
for having refresher training through the phone. This acceptance
rate is indicative that whichever CHW that will be selected for
inclusion into the training program will be motivated to actually
login and do the training.

The MOTS project was focused on strengthening the
healthcare system [28]. One of the ways the MOTS program was
going to achieve this was working with CHWs who actually do
home visits and provide periodic reports to the PHUs. During the
interviewing process, the CHWs were asked to bring their
Household and Surveillance registers. This was because the two
IVR modules that were going to be sent are emphasizing the
need for reporting. Of all CHWs interviewed, 97.7% presented a
household register (H. Register) and 96.6% presented a
Surveillance register (S. Register). The MoHS recommends that all CHWs need to be in possession of these two registers for
purposes of timely reporting [29].

One of the key functions that will be played by the CHWs is to
be able to read the welcome SMS [30]. This therefore
necessitated the CHWs to be tested for the ability to read. A
given text “I promote the health of mothers and children in my
community” was supposed to be read out loud by the CHW in
his or her preferred language. From the results, 87.1% of the
CHWs interviewed could actually read (Reading) an additional
assurance that actually logging into the system by the CHWs will
not be a problem.

The other important issue that was looked into with the CHWs
was the functionality of their mobile phones. The study focused
on the functioning phone keys and had a clear phone screen.
This is because as the CHWs listen to the IVR, they will be asked
to press some phone keys as a form of response to the quiz, and
for them to be able to kick start the training, the CHWs should
read the initial message on a clear phone screen. 80.7% (Phone
screen) of all CHWs had a phone with a functioning screen at the
time of the survey. This therefore meant that up to 20% of all
CHWs with mobile phones cannot read any message sent to
them since the screen was not visible. Further still 82.6% (Phone
keys) of all CHWs with mobile phones had phone keys
functional, with all numbers visible and dialling in (Figure 2).

Figure 2: Key CHWs considerations for the MOTS refresher
program

CHW language determination

The MOTS program will be facilitated through IVRs. For this to
be effected there is a need for the developed content to be
tailored into the language that is easily understood and
interpreted by the CHWs. Each CHW interviewed was put to a
test about this aspect of the program, through confirming that
there is a particular language they are comfortable interacting in
during the interview and further can actually read in that
language or prefers another for reading purposes. Results show
that there were basically 3 common languages used as a
medium in the 5 chiefdoms, these include Mende, Krio and
English. The most spoken language was Krio with a 52.65%
prevalence followed by Mende with a 45.08% score with English
having the least spoken rate of 2.27%. However, it was revealed
that even though majority of the CHWs are not comfortable
speaking English, it’s the only language they can read with ease.
In this regard 82.95% of all CHWs interviewed could only read
and interpret an English text without struggling. It is important
to note that there was a 12.12% of CHWs who could not attempt to read text in any form of languages presented to them. This is
contrary to the MoHS guidelines recommendation of practice
that emphasizes a CHW should be able to read and write [1]
since they have a responsibility of reading and writing in their
deliverables (Figure 3).

Figure 3:CHW language determination for MOTS

CHWs capacity determinants

The MoHS provided guidance to the MOTS project that
included working with CHWs that have been trained in the
approved national curriculum for CHWs [31]. The MoHS further
recommended that the CHWs to be included in the MOTS pilot
should be recently trained since the New Curriculum was rolled
out in the past year. This was also deliberate to focus on the
CHWs who are actually active and have been carrying out their
quality household visits as stipulated in the CHW policy
guidelines. Results of the survey show the extent to which the
CHWs contribute to the desired guidance. When focusing on the
CHWs who have been trained in the generic package, 87.5% of
CHWs claimed to have been trained in the 7-12 months
preceding the survey, with only 1.9% claiming to have been
trained more than 12 months preceeding the survey period. This
revelation confirms the MoHS recommendation that majority of
the CHWs must have been trained within this same year of data
collection.

During the capacity building process, the CHWs are facilitated
to map out their actual coverage area by households. The
mapping exercise is in line with the national recommendation of
each CHW allocated not more than 30 households. During the
capacity building week, all CHWs include the numbers of their
households into their register for follow up. Results show that
42.8% of the CHWs interviewed oversee the recommended 30
or fewer households in a given community. The second largest
category shows that 39% of the CHWs oversee more than 50
households. MOTS anticipate that the CHWS need to have ease
of coverage to be able to actually pass on the messages learned
from the IVRs during the refresher MOTS service.

The other aspect was to determine whether the CHWs were
actively visiting the households they oversee. Only 44.3% of the
CHWs had visited their households 2 weeks before the survey
while 18.9% of the CHWs assessed had taken more than 4 weeks
without visiting the households. It’s a recommended practice for
CHWs to perform adequate quality house hold visits since they are the first line of affordable healthcare (Figure 4 and Table 4)
[31,32].

Figure 4: Blood versus ECG-derived potassium values during
dialysis.

Last household Visit

No

Before Survey

No

%

0-2 weeks

117

44.30%

2

3-4 weeks

97

36.70%

3

>4 weeks

50

18.90%

4

Can't recall

2

0.80%

Face-to-face training

No

Before Survey

No

%

1

0-6 months

45

17.00%

2

7-12 months

213

87.50%

3

>12 months

5

1.90%

4

Never

1

0.40%

Households overseen

No

Number

No

%

1

<=29

113

42.80%

2

30-40

32

12.10%

3

41-50

25

9.50%

4

>50

103

39.00%

Table 4: CHWs capacity determinants.

CHWs MOTS implementation considerations

CHWs participation in the MOTS requires a few considerations
that contribute to the enabling environment that facilitate
modular IVR training. These include the following: the training
content for services they offer, their level of education, the
mobile network status at the CHWs home and any anticipated
challenges.

From the interviews conducted, CHWs were concerned about
these challenges during MOTS: a 91.7% having difficulty in
charging their phones, 45.1% fearing very poor network, and a
12.9% claiming that they may have difficulties operating the
phone. 9.8% of the CHWs felt that the status of their batteries
would be a problem since they deemed it to be bad. It is
important to note that a 7.2% of the CHWs did not have any
anticipated challenge. This therefore means that only 7.2% of
the CHWs were totally free from fear to participate in the MOTS
service as far as mobile phones were concerned.

For the CHWs to receive the initial message, the geographical
location should have sufficient mobile network. An observation
was done targeting the number of bars on the phone of the
CHW at the time of interview. 32.2% of the CHWs had the
required three bars for a call to be placed and an IVR to be
listened to. Another 24.6% of the CHWs presented with two bars
in the location of the interview place. This observation was
included on assumption that the CHW was interviewed at his
most convenient place able to call in for the modular IVRs.

The study required the level of academic potential to
determine the level of capacity building and supervision that will
be offered to the CHWs. If the study reveals that majority of
CHWs have a none or low level of education, the project would
be able to tailor the training and mentorship support to the level
of education that the CHWs portray. From the results, only
11.7% of the CHWs had no educational level. These 11.7%
meeting the selection criteria will need the highest level of
support able to complete the training. The study also revealed
that 40.2% of the CHWs have gone up to senior Secondary level
and therefore should easily comprehend the navigation around
the mobile phone. This was followed by a 29.2% that completed
junior Secondary.

The MOTS service initially focuses on vaccination and
surveillance for outbreaks within the community. The principle
of having a service that can be used to refresh CHWs, was aimed
at making sure that whatever is discussed through the service
can be translated into a counselling objective for the CHWs.
MOTS therefore included a question focusing on what is
discussed at household level, looking for anything around
vaccination and other common services as guided by the CHW
policy framework for Sierra Leone [32]. Discussions and support
around child vaccination scored a 95.9%, malaria prevention
scored 96.5%, and breastfeeding support scored a 93.9%. The
least discussed theme that was included in the study was the
encouragement of male involvement with a 75.4% score (Table
5).

CHW Anticipated challenges during the Training

No

Challenge

Freq.

%

1

Difficulty in charging the phone

242

91.7%

2

Poor network

119

45.1%

3

Difficulties to operate the phone

34

12.9%

4

Bad phone battery

26

9.8%

5

None

19

7.2%

Services offered by the CHWs

No

Services offered

Freq.

%

1

Malaria Prevention

255

96.6%

2

Child Vaccination

252

95.5%

3

Hand washing

251

95.1%

4

Breastfeeding

248

93.9%

5

Male involvement

199

75.4%

CHW Educational level

No

Level

Freq.

%

1

Pre-primary

1

0.4%

2

Primary

26

9.8%

3

Junior Secondary

77

29.2%

4

Senior Secondary

106

40.2%

5

Tertiary

22

8.3%

6

University

1

0.4%

7

None

31

11.7%

CHW’s phone Network Status

No

Network bars

Freq.

%

1

One (25%)ÃÂ

18

6.8%

2

Two (50%)

65

24.6%

3

Three (75%)

85

32.2%

4

Four (100%)

43

16.3%

5

No bar at all

11

4.2%

6

Not applicable

42

15.8%

Table 5: CHWs MOTS implementation considerations.

PHU in-charges’ considerations for MOTS refresher
program

The MOTS implementation framework recommends that the
PHU in-charges shall be the frontline and immediate supervisors
to the CHWs [33]. They are responsible for making sure that
CHWs login and complete the modular IVRs in the stipulated
time of 4 weeks. For the PHU in-charges to perform this role
there are a number of considerations including possession of a
functional smartphone to monitor the CHWs online, looking at
login, starting and completion of modules. From the assessment
only 56.25% of the PHU in-charges had a smartphone. This
therefore means that 43.75% of the PHUs assessed cannot
provide online supervision for the CHWs during the training
period.

The perspective of the PHU in-charges towards using a mobile
phone service to refresh CHWs was also assessed. The PHU incharges
were asked whether they would recommend their
CHWs to actually have training using a mobile phone. Almost all
(96.9%) PHU in-charges interviewed strongly recommended the
utilization of a mobile phone to refresh CHWs. This presented a
great mindset for the program since the CHWs supervisors
presented a positive attitude towards the MOTS service.

The PHU in-charges’ ability to supervise CHWs was
ascertained by asking them to provide a list of CHWs attached to
the PHU. This aspect also focused on whether the list exits at the
PHU, better still if they had a schedule for CHW involvement. In
this regard 90.6% of PHU in-charges had the lists pinned in the
health facility. It is important to note that 9.4% of the PHU incharges
did not have the list of the CHWs with them, and this
could be a hindrance to the supervision mechanism for a CHW
(Figure 4).

PHU in-charges’ supervision capacity and
anticipated challenges

PHU in-charges needed to articulate the anticipated
challenges CHWs would face during the MOTS service. In this
regard 50% of the PHU in-charges pointed out access to charging
facilities for CHW phones due to a challenge of power and trek
taken to have phones charged. Another 59% of the PHU incharges
pointed to inadequate mobile network and struggles to
get a good signal to access the MOTS system.

The PHU in-charges also needed to provide the number of
CHWs in the catchment [34]. The PHU in-charges who
supervised up to 10 CHWs contributed 50% of the sampled
PHUs. This is in line with the MoHS structures since most PHUs
included in the study are MCHP and have a relatively small
geographical coverage. 38% of the PHU in-charges provide
supervision to 11-20 CHWs and 13% provide supervision to
21-30 CHWs (Table 6).

The MoHS recommended for MOTS service to consider the
role played by the households. All CHWs who participate are
expected to eventually perform household visits and the actions
are supposed to guide household counselling [35,36]. The
households interacted with during the survey needed to first
ascertain whether in the 2 months preceding the study, they
were actually visited by a CHW. Results shows that 83.1%
households surveyed had been visited by the CHW in the period
of 2 months before survey. This very high percentage speaks to
the fact that the MoHS in Sierra Leone is facilitating a functional
and operating CHW. This will be an added advantage for the
MOTS service since there is assurance that the CHWs actually do
perform their household visits.

The household were asked to mention the services they
received from the CHWs. These services were bundled in
accordance to the guidance provided by the MoHS policy
document for CHWs [1]. The outcome of this particular issue is
in line with what the CHWs claimed to have been doing during
the visit, however the percentages are much less than the ones
claimed by the CHWs. The highest point of support being offered
by the CHWs is counselling and support for malaria prevention
with 80%. Adequate water, hygiene and sanitation practices
scored second with a 75.4%, 29.2% of the households did not
mention child vaccination as one of the issues CHWs support
them on. This gives the MOTS a basis to contribute and add
value to the support required from CHWs.

All households who reported having been counselled by a
CHW, were asked to rate the usefulness of the information
received. The assessment rating process was guided by the 3
bean selection. Household member interviewed were asked to
pick the beans in relation to how the information supported
them perform a given practice or action. The rating was
between 0-3 with 0 being not useful and 3 being very useful.
Results from the survey showed that only 0.4% of the
participants did not see the usefulness of the information
provided, with 6.6% seeing the information as useful and a
93.0% of the participants rating the information as very useful.
This gives an edge to the MOTS service that the community
actually have great trust and respect [37] for the work being
done by the CHWs and therefore the refresher information shall
be taken with utmost respect and trust by the community (Table
7).

Anticipated challenges

No.

Challenge

Freq.

%

1

Poor network

19

59

2

Inaccessible charging facilities

16

50

3

Lack of network

5

16

4

Illiteracy

4

13

5

Lack of top-up

1

3

6

Effectiveness of the training

1

3

CHWs supervised

No.

Ranges

Freq.

%

1

0-10

16

50

2

11 to 20

12

38

3

21 to 30

4

13

Table 7: Household appreciation of CHWs role.

CHWS who met the inclusion criteria for MOTS
service

In order to select the required CHWs for the inclusion in the
MOTS service, a systematic filter process was employed
following the criteria as stated in the protocol [20]. Filtering
process included CHWs in the geographic location, willingness to
participate, reports to the PHU and has a functional mobile
phone. After these filters, the names were forwarded to the
MoHS team to select the 125 based on the degree of activity.

All CHWs (100%) proved their residence of the project area.
The second filter performed was to ascertain the CHW’s
willingness to participate and 99.2% of the CHWs were willing to
participate. The same percentage (99.2%) was able to mention a
PHU within the coverage area. 82.2% of the CHW’s phone keys
were functional on their mobile phone and 79.2% of the CHWs
phone had a clear screen.

The functionality of CHWs to participate in the MOTS service
was 79.2% (209). These therefore met the inclusion criteria for
MOTS service. However, the project set out to work with only
125 CHWs, and this necessitated the utilization of another
selection process. This being a pilot, the project needed active
and functional CHWs. A team from the DHMT and the MoHS
CHW-Hub was asked to review the list of 209 and select 125
CHWs (Figure 5).

Figure 5: CHWs meeting the inclusion criteria for MOTS

PHU in-charges meeting the inclusion criteria for
MOTS

The inclusion of PHU in-charges into the MOTS service aimed
at adequate follow up and support during the training [38]. The
PHU in-charges must have a smartphone and offer supervision to CHWs. All PHU in-charges (100%) interviewed supervise
CHWs.

The study proposed another variable to prove that CHW
support actually happens, the PHU in-charges needed present a
list of CHWs and their contacts, including a work schedule [39].
In this regard 90.6% of PHU in-charges met these criteria.

Possession of a smartphone indicated only 40.6% of PHU incharges
met this criterion. Having a smartphone meant that the
platform for follow up of CHWs would easily be installed on the
phone for monitoring progress (Figure 6).

Figure 6: Blood versus ECG-derived potassium values during
dialysis.

Discussion

Among the many forces driving the eminent need for
innovation in healthcare is timely access to health services in the
most remote locations and the urge to reach the most
vulnerable populations. The traditional care delivery models are
being overwhelmed as a result of the rapidly increasing
prevalence of chronic disease [40]. There are looming shortages
of frontline mainstream healthcare providers, raising costs of
care and a suffering productivity of the health workforce due to
multiple priorities at the point of service provision. Information
and communication technologies offer a window for
tremendous innovation in healthcare. These offer considerable
promise for enabling entirely new models of healthcare both
within and outside of formal systems of care, and offer the
opportunity to have a larger and more efficient public health
impact. A number of tools exist to monitor and capture real-time
data about individuals’ health status through user input into
mobile applications [41]. Further, decision support tools are
increasingly being developed to facilitate the health system to
better understand, access, and make choices about the
population served.

Opportunities for mobile technologies to play a pivotal role in
health services, particularly in low-income countries, are
increasingly being recognized as mHealth can now support
performance of health workers through the dissemination of
clinical sensitive updates (Continuous Medical Education),
offering learning materials, and reminders, particularly in underserved rural locations where CHWs are considered a very
important frontline cadre to offer health services [42-44]. Until
recently there has generally been lack of mHealth applications
and services operating at scale. There has been one most
common use of a one-way text message and phone reminders to
encourage follow-up appointments, healthy behaviors, and data
gathering [45]. Innovative mHealth applications for CHWs
include the use of mobile phones as job aides, clinical decision
support tools, and for data submission and instant feedback on
performance [44] with the MOTS service facilitating the IVR
channel for capacity building and knowledge assessment. By
harnessing such an innovation among diverse populations, there
is a promising suggestion that mHealth can be used to deliver
increased and enhanced healthcare services to individuals and
communities, while helping to strengthen health system at the
lowest level of care [42].

With the current consistent shortage and inadequate
distribution of the health workers in Sierra Leone, the MoHS is
increasingly relying on the CHWs for the delivery of primary care
[46]. The MoHS intervention to operationalize the CHWs has
gone a long way in ensuring that each PHU has fully trained and
equipped CHWs. Evidence from this study shows that 79.2% of
all CHWs assessed were functional for MOTS-an indication that
MoHS has done a tremendous job in rolling out the CHW policy
framework for Sierra Leone [1,23]. MoHS’ support to the CHWs
is evidence of contributing to the effectiveness in delivering
health services to communities and the improvement of health
outcomes across specific thematic area in healthcare as stated in
the healthcare package for the country [1]. Even with a very
commendable functionality rate of 79.2%, CHWs remain
vulnerable to an inadequate and very low motivation structure,
poor or non-existent financial remuneration, inaccessible terrain
and isolation [47]. The implementation of MOTS will be coupled
with non-existent mobile network, existent but unreliable
mobile network, difficulty in finding all round charging system
and phones having poor batteries.

The vision of the MoHS in Sierra Leone is to have an
adequate, well-managed and efficient system in place that will
create a motivated human resource of health fully empowered
staff to provide equitable access and distribution of services
leading to a healthy and productive Sierra Leone [48,49]. The
MOTS assessment focused on key indicators that contribute to
this, and there was a 90.6% of PHU in-charges who actually
performed the function of supervision for CHWs. It therefore
implies that the 9.4 PHU in-charges were providing ad hoc,
inadequate, and non-existent support supervision to the CHWs
attached to their PHUs [50-52]. Since MOTS requires the
availability of a smartphone for the PHU in-charge to
functionally support MOTS, only 40.6% of the PHU in-charges
managed to meet this functionality requirement. If the Sierra
Leone Health sector is going to adapt the MOTS service, there is
need for availability of smartphones in addition to making
charging facilities available, and dealing with lack of network.

CHWs are considered the backbone of an efficient healthcare
system in low-income countries like Sierra Leone [53]. For the
CHWs to perform effectively there is need for refresher of
trainings. The refresher training needs to be carefully planned and can be done face-to-face [54] or even through voice
messages which is what MOTS would suggest, sending IVRs
through the mobile phone. This in the long run provides an
effective way of reminding CHWs and providing guidance on key
actions expected [55] at the counselling level. With a 99%
acceptance rate, CHWs are willing to be refreshed through
mobile phones. This willingness points to the fact that
technology if rolled out in a collaborative and systematic
approach can contribute to capacity building of CHWs.

Recommendations

Mobile network infrastructure is key in MOTS
service roll out

The baseline exercise revealed that it is paramount to have
the mobile network infrastructure assessed and understood for
a successful implementation. Implementing through a strong
and reliable network provides a structured foundation for a
good mobile process [56]. At the local level there is a distinct
difference between availability of network and reliability of that
network. For a large scale roll out, these two factors have to be
studied well before implementation kicks off.

Implementation through the government health
system approach is key

For MOTS to yield the desired results there is need for the
pilot and implementation mechanism to deliberately work with
the Sierra Leone healthcare system. This is because health
systems strengthening indicate the actions taken to achieve the
goal of universal health coverage that includes access to quality
essential healthcare services at the community level [56]. This
baseline study was rolled out in a collaborative function with the
MoHS different technical working groups and the DHMT. This
working relationship provided a smooth preparatory platform
and approval for the study.

Work through a functional CHW to deliver on MOTS

If MOTS is to strengthen the system and further present
evidence that the MoHS can actually adopt the platform as a
refresher tool, there is need for the operations of MOTS to
happen with a functional CHW. This is because a functional CHW
easily bring care closer to where mothers and children are and
therefore contributes to the increase in equity and access
immediately after the training [56]. If this implementation
strategy presents an opportunity for cutting costs and delivering
evidence with the current minimal resources, then the MoHS
can adapt the platform for further programming.

Conclusion

Utilization of the modular IVRs through the MOTS platform to
facilitate the refresher training to CHWs is very possible. This is
because from the assessment, 79.17% (209) CHWs met the
inclusion criteria for MOTS. At the CHW level, the willingness to
participate was rated at 99%. This coupled with the MoHS
support will contribute to the success of the program.

Acknowledgements

This project has received funding from the Innovative
Medicines Initiative 2 Joint Undertaking under grant agreement
EBODAC (grant nr. 115847). This Joint Undertaking receives
support from the European Union’s Horizon 2020 research and
innovation programme and European Federation of
Pharmaceutical Industries and Associations (EFPIA). The authors
would also like to acknowledge the contribution of the MOTS
advisory group of EBODAC including, Mc Kenna Paula, Oriol
Mathieu Valérie, Thomas Mooney and Anneleen Vuchelen. Mr.
Alluie Bangura the principle investigator for the MOTS roll out,
the 5 data entry team members Dauda Sesay, Alhaji Kallon,
Ibrahim Conteh, Unisa Jalloh and Josephine S Vanja, the 2
research associates Etta F. Charles and Jamil S Jabbie, the 6
research assistants Edward Ngoka, Mustapha O Sharif, Ceasor M
kargbo, Muhamed lamin, Abdulrahman Kamara, and the
Ministry of Health and Sanitation of Sierra Leone for their
tremendous efforts in having this piece of work a reality.

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